Hindawi

International Journal of Alzheimer’s Disease

Volume 2018, Article ID 3280621, 7 pages
https://doi.org/10.1155/2018/3280621

Research Article
Cognitive Assessment Test: Validation of a Short Cognitive Test
for the Detection of Mild Cognitive Disorder

Kelly Estrada-Orozco ,1,2 Kely Bonilla-Vargas,1 Francy Cruz,1 Oscar Mancera,1

Miguel Ruiz,1 Laura Alvarez,1 Rodrigo Pardo,1,2 and Humberto Arboleda2,3
1
Clinical Research Institute, National University of Colombia, Colombia
2
Neurosciences Group, National University of Colombia, Colombia
3
Institute of Genetics, National University of Colombia, Colombia

Correspondence should be addressed to Kelly Estrada-Orozco; kpestradao@unal.edu.co

Received 18 February 2018; Revised 27 May 2018; Accepted 31 May 2018; Published 2 July 2018

Academic Editor: Francesco Panza

Copyright © 2018 Kelly Estrada-Orozco et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.

Introduction. Cognitive disorders are a clinical and research challenge; in particular, the mild cognitive disorder (MiCD) requires
diagnostic suspicion and tools with adequate performance for its detection. The objective of this study was the validation of a short
cognitive test (CATest) for the detection of MiCD in population of 50 years or more. Methods. A diagnostic accuracy study was
assembled and performed in a prospective cohort. A consecutive sample of 200 Colombian subjects who represented the whole
spectrum of the condition of interest allowed us to reach the objective. Validity was determined by concurrent criteria. The cut
points were determined by the ROC curves considering the best overall performance and accuracy of the test. Results. CATest was
validated to detection of MiCD at a cut-off point of 18. As a result, scores lower than 18 classified the participants as MiCD. At this
cut-off point, CATest showed sensitivity of 84.3% (CI 76 to 90.16), specificity of 71.4% (CI 95% 61.8 to 79.43), positive predictive
value of 75% ( 95% CI 66.79 to 82.42), and area under curve AUC 0.8518 (standard error SE 0.0265). Discussion. CATest has an
adequate performance as a short cognitive test for the detection of MiCD. Its performance is superior to MiniMental and similar to
Montreal Cognitive test (MoCA) according to the data reported in the literature. The advantages over other tests are the evaluation
of all cognitive domains, time of application, and easy interpretation of results. CATest is a free use alternative for MiCD detection.

1. Introduction at compensating for the faults observed in the activities of his

Aging of population is one of the issues that most concerns
the health system [1], due to the numerous comorbidities that
accompany this population [2], the consumption of resources
derived from their care, and the high burden of disease in
terms of disability from many of these diseases.
Dementia represents a high burden of disease that mainly
affects the over 65s [1, 3]. In recent years, dementia as a term
has been replaced by major cognitive disorder due to the high
stigma associated with this disease.
During the aging process, changes occur within the cog-
nitive domains, many of which go unnoticed, especially if the
changes are small and demands on the environment in which
the patient operates are small. Other changes, on the contrary,
obligate the individual to generate a series of strategies aimed
or her daily life.
Cognitive disorders are classified according to the Diag-
nostic and Statistical Manual of Mental Disorders DSM 5 [4]
in mild neurocognitive disorder (MiCD), if the alteration in
the higher brain function is not so pronounced as to generate
difficulties in the activities of the individual, and major neu-
rocognitive disorder (MCD) (a term that replaces dementia
included until the previous version of the DSM IV), if the
alteration of these functions affects their functionality at
work, social, and/or family level. The definition includes a loss
of these higher brain functions, after they have had a habitual
development throughout life.
According to the latest pronouncement of the World
Alzheimer Report 2015 [3] which details the global prevalence
of dementias, a total of 46.8 million people living with MCD
2 International Journal of Alzheimer’s Disease
were estimated for the middle of 2015. On the other hand,
MiCD affects between 3% and 20% of adults over 65 [5–
7]; in other studies, prevalence greater than 22% has been
found [8–13] and the prognosis in general practice is variable:
approximately 25% of people develop MCD within three
years after diagnosis, but about 40% return to normal [14].
Evidence on factors that are related to the progression
from mild cognitive disorder to major cognitive disorder is
becoming more common [15–17], and many of these factors
that have been identified are largely modifiable [18]. This new
evidence, among many other reasons, allows the considera-
tion of mild cognitive disorder to be of vital importance at a
clinical and social level.
Diagnosis of cognitive disorders is important especially
in the early stages because many of its causes are potentially
reversible such as depression, side effects of medication,
excess alcohol, thyroid disease, vitamin deficiencies, and
sleep disorders. In addition, even in the case of primary neu-
rodegenerative disorders, early detection allows mitigate fac-
tors that are known to lead to more rapid progression of the
disease [15, 16], and this mitigation will ultimately slow pro-
gression.
Another benefit of early disease detection that is often
overlooked is the extra time an individual will have to arrange
their financial and legal obligations regarding end of life care
[19].
Science also does not overlook the benefits of early and
accurate screening, as it also allows affected people to decide
whether or not to participate in clinical trials, including
experimental therapy trials that can slow or stop the progres-
sion of the disease [19, 20], a field that has worked for many
years with no conclusive results so far.
At present there are a large number of studies available
that represent adequate evidence on the diagnosis of major
cognitive disorder. The challenge for health professionals and
science lies in the beginning phases of this disorder that go
unnoticed for the subject and health care personnel. This lim-
its the ability to predict the emergence of a syndrome of great-
er complexity and the potential of a high degree of disability
for the individual in the future.
There are tools that have been validated to detect neu-
rocognitive disorder [21–27]; however the target population
is over 65 years and accuracy and reliability present enormous
variability to diagnostic MiCD. The above can be explained by
the differences in population where it has been applied, diag-
nostic criteria to define the condition, and complexity and
scope of the tools.
The aim of this study was validate a tool (cognitive assess-
ment test (CATest)). for the detection of mild cognitive dis-
order in subjects aged 50 years or older, taking from the liter-
ature diagnostic elements with the highest level of diagnostic
accuracy for this population, which contribute to a greater
operative performance of the tool.
2. Methods
2.1. Design of Study. Diagnostic test accuracy study assem-
bled in a prospective cohort.
2.2. Participants. A cohort with a total of 200 consecutive
Colombian participants enrolled in the National University of
Colombia Clinic of Dementia was included. Inclusion criteria
were (1) age equal to or greater than 50 years, (2) at least
1-year education, and (3) adequate vision and hearing to
complete neuropsychological (NP) testing. Exclusion criteria
were (1) history of severe brain trauma; (2) lifetime history of
schizophrenia, manic-depressive disorder, or schizoaffective
disorder; (3) current alcohol or drug abuse/dependence; (4)
obstructive sleep apnea syndrome; and (5) significant disease
or unstable medical condition (i.e., chronic renal failure,
chronic hepatic disease, or severe pulmonary disease) and
thyroid disease with no hormonal substitution.
2.3. Sample Size. Sample size was calculated in 200 patients;
the parameters used in the calculation were prevalence of
cognitive disorder 40%, sensitivity 90% or higher, and speci-
ficity 80% or higher.
2.4. Medical Evaluation. A neurological clinical assessment
was performed. The review of personal clinical history, men-
tal and neurological examination, cognitive screening tests
(MiniMental MMSE 2 [28], Neuropsychiatric Inventory
[29]), and functionality scales (Lawton and Brody Scale [30,
31]) was completed, as well as review of tests such as lipid pro-
file, glucose, thyroid tests, levels of vitamin B12 and folic acid,
tests of hepatic and renal function, and serology VDRL.
In the participants with abnormal results in cognitive
screening tests, a brain image was requested by magnetic
resonance and reviewed in a consultation during follow-up.
2.5. Neuropsychological (NP) Evaluation. Neuronorm-Col
[32] diagnostic NP battery consisted of tests of (1) language
tests (Boston Naming Test, Token Test), (2) visuoconstructive
skills (Rey-Osterrieth Complex Figure), (3) attention and
executive functions (WAIS-III Digit Retention tests, Corsi
Cubes, trail making test A and B (TMT A and B), digit-
symbol test (SDMT), Stroop color word Test, Tower of Lon-
don test, Win- dingo Card Sorting Test and Verbal Fluency),
and (4) memory (Free and Cued Selective Reminding Test).
2.6. Diagnostic Classification of the Participants. Cognitive
classification was determined via a multidisciplinary consen-
sus meeting including (neurologist, neuropsychologist, and
neuroscientist); criteria to classification of cognitive disorder
from DSM 5 [4] were used and NP testing, medical and social
history, daily functioning, reported cognitive symptoms, and
neuroimaging findings were reviewed.
2.6.1. Normal Performance. Criteria for normal performance
were (1) no more than one test score lower than expected
within a cognitive domain and (2) no more than two scores
lower than expected across domains, with the threshold cor-
responding to 1.0 standard deviation (SD) below age adjusted
control means.
2.6.2. Cognitive Disorder (CD). NP criteria for MiCD in-
cluded scores on at least two individual tests within a cog-
nitive domain, greater than 1.0 SD below education and age-
corrected. MCD included scores on at least two individual
tests within a cognitive domain lower than 2.0 SD.
International Journal of Alzheimer’s Disease 3

Table 1: Characteristics of the participants.

TOTAL Men Women

N=200 CI 95% n= 66 CI 95% n= 134 CI 95% P Value
∗
Age (Years) 66.53( 8.84) (65.3-67-7) 66.65 (9.94) (64.25-69) 66.5(8.28) (65-67.9) 0.9105
Education (Years)∗∗ 16(1-29) 16(1-29) 15(2-25) 0.5183
n/200 (%) CI 95% n/66 (%) CI 95% n/134 CI 95%
Civil Status
Married 90(45) (38.1-51.9)% 39(59) (47.2-71)% 51(38) (29.8-46.3)% 0.0050
single 28(14) (9.2-18.8)% 7(10.6) (6.5-23.8)% 21(15.67) (9.5-21.8)% 0.3312
widower 24(12) (7.5-16.5)% 2(3) (0-7.2)% 22(16.41) (10.1-22.7)% 0.0060
Divorced 17(8.5) (4.6-12.4)% 2(3) (0-7.2)% 15(11.19) (5.9-16.5)% 0.0507
No information 41(20.5) ∗-∗ ∗-∗
∗
Mean (standard deviation (SD)). ∗∗ Median (range).

2.7. Cognitive Assessment Test (CATest). The construction of
CATest is the result of a systematic review performed by the
National University of Colombia group of neurosciences.
CATest includes the following.
The immediate recovery test: it consists of a list of 5 words,
which allows evaluating episodic short-term memory and
attentional functions during the first trial. In the test, the
subject is asked to repeat 5 words during two trials, and after a
short period of time, with distracting elements, he is asked to
remember the 5 words. The recovery must be done sponta-
neously.
The clock drawing test: it evaluates different cognitive
skills, including attention, visuospatial abilities, abstract con-
ceptualization, and executive control. During the drawing test
of the clock, the participants are asked to draw a clock that
has all its parts (circumference, hour hand, minute hand and
second hand, and numbers) and indicate on it the time 11:10.
The drawing of the circumference, the numbers in correct
position and order, and the location of the requested time are
qualified. There are no time limits to complete it.
The phonological fluency test: it is applied in a time of 1
minute; it has a restrictive character of phonological type, for
the production of words limiting the beginning of the same
to a letter that is indicated when giving the instruction of the
test.
CATest utilizes 2 letters: “M” or “P”, and the double selec-
tion is done to prevent learning bias during the serial applica-
tion.
CATest is rating from 0 to 21, considering 15 points to mem-
ory evaluation (Supplementary materials (available here)).
2.8. Analysis. Baseline distributions of the demographics,
marital status, and education were presented according to the
distribution of normality of each variable. A subgroup anal-
ysis by diagnostic (normal performance, MiCD, and MCD)
was presented.
The receiver operational characteristic (ROC) curve anal-
ysis [33] was utilized to characterize the performance of the
CATest in distinguishing MiCD patients from normal healthy
controls and MiCD patients from MCD patients.
Optimal cut-off point was determined from a sensitivity
analysis of the operative characteristics of the test; it included
sensitivity, specificity, positive predictive value, negative pre-
dictive value, true positive (TP), and false positive (FP) rates,
Likelihood ratio (LR + and LR -) as well as diagnostic odds
ratio (DOR).
Operative characteristics of each cut-off evaluated in the
sensitivity analysis were modulated considering the propor-
tion of accurately classified patients and the cost of making a
false positive mistake or a false negative mistake. As criteria to
define it, FP rate was maximized for MiCD and TP was maxi-
mized for MCD.
The results were presented with the 95% confidence inter-
val.
Data were analyzed with statistical software STATA  V.13.
3. Results
A total of 339 participants were evaluated between March
2016 and November 2017. 109 were excluded (22 active psychi-
atric disease, 87 other causes: hearing loss, Parkinson disease,
history of severe brain trauma, and cognitive disorder since
childhood), and 30 participants did not complete the neu-
ropsychological test. 200 participants were included.
The prevalence of cognitive disorders in the sample was
51% (95% CI 44.1-57.9) with a prevalence of 32% (CI 95% 25.5-
38.5) for MiCD and 19% (CI95% 13.6-24.4) for MCD.
The study sample consisted predominantly of women
(67%), average age of the participants were between 53 and
66 years (SD 8.84), and there were no differences between the
ages by sex in the study with men being on average 66.65 years
(95% CI 64.25-69) and women 66.5 years (95% CI 65-67.9) (P
0.9105).
The educational level measured as the median of years of
schooling was 16, Rank (1-29), and 45% of the participants
were married (Table 1).
According to diagnostic category, statistical differences
were not found in age of participants in normal performance
group and MiCD ( average 64.8 and 65.5 year, respectively);
however, the age in MCD group presented statistical differ-
ences ( 72.6 (CI95% 69.2-75.9)) (Table 2).
Women represented the highest proportion in the groups
of normal performance subjects and MiCD, but this trend
was not observed in the group of patients with MCD (women
34.21%) (P < 0.0001).
 4

Table 2: Characteristics of the participants by diagnosis category.

TOTAL Normal performance MiCD MCD
N=200 IC 95% n= 98 IC 95% n = 64 IC 95% n = 38 IC 95% P value
Age (years)∗ 66.54(8.86) (65.3-67-7) 64.83( 7.487) (63.34-66.31) 65.53(8.32) (63.49-67.56) 72.6(10.48) (69.22-75.96) < 0.001
Women 134(67%) (60.5-73.5) 75(76%) (68.1-84.5) 45(70.31%) (59.1-89.5) 13(34.21%) (19.1-49.3) < 0.001
Education (years)∗∗ 16(1-29) 16(4-24) 16(3-25) 11(1-29) 0.001
Category (%) n/200 CI 95% (%) n/98 CI 95% (%) n/64 CI 95% (%) n/38 CI 95% < 0.001
< 5 years 22(11) (6.7-15.3) 4(4) (0.2-8) 2(3.1) (0-7.4) 16(42.1) (26.4-57.8)
>5 - 11 years 35(17.5) (12.2-22.8) 19(19.38) (11.6-27.2) 13(20.31) (10.5-30.2) 3(7.9) (0-16.5)
>11-16 years 69(34.5) (27.7-41.1) 32(32.65) (23.4-41.9) 24(37.5) (25.6-49.4) 13(19.1) (19.1-49.3)
>16 years 74(37.5) (30.3-43.7) 43(43.87) (34.1-53.7) 25(39) (27.1-51) 6(15.78) (4.2-27.4)
MiCD: mild cognitive disorder and MCD: major cognitive disorder.∗ Mean (standard deviation (SD)). ∗∗ Median (range).
International Journal of Alzheimer’s Disease
International Journal of Alzheimer’s Disease 5

Table 3: CATest performance at cut-off point.

Cut-off point--> 14 18
CI 95% CI 95%
Sensitivity 86,80% 72,67 - 94,24 84,30% 76 - 90,16
Specificity 88,90% 83,12 - 92,85 71,40% 61,80 - 79,43
Positive predictive value 64,70% 50,98 - 76,36 75,40% 66,79 - 82,42
Negative predictive value 96,60% 92,38 - 98,55 81,40% 71,89 - 88,21
Proportion of false positives 11,10% 7,14 - 16,8 28,60% 20,56 - 38,19
Proportion of false negatives 13,20% 5,75 - 27,32 15,70% 9,89 - 23,97
Accuracy 88,50% 83,33 - 92,21 78,00% 71,76 - 83,18
Diagnostic odds ratio 52,8 18,28 - 152,48 13,44 6,73 - 26,8
Youden’s J index 0,8 ∗∗ 0,6 ∗∗
Likelihood ratio LR (+) 7,82 4,96 - 12,29 2,95 2,13 - 4,08
Likelihood ratio LR (-) 0,15 0,06 - 0,33 0,22 0,13 - 0,34

Time of application was varied from analysis by diagnostic

groups (normal performance 3 minutes, MiCD 4 minutes and
42 seconds; MCD 6 minutes, SD 59 seconds).

Figure 1: ROC curve and value of correct classification (AUC).
Years of schooling also proved to be a variable that differ-
entiated the groups (median of 11 years in MCD group and
16 years in normal performance and MiCD groups) (P
0.0001).
ROC curves were developed (Figure 1) to select the most
accuracy cut-off point (normal performance, MiCD). After
the sensitivity analysis, CATest was validated for the detection
of MiCD at a cut-off point of 18. As a result, scores lower
than 18 classified the participants as MiCD. At this cut-off
point, CATest showed sensitivity of 84.3% (CI 76 to 90.16),
specificity of 71.4%, (CI 95% 61.8 to 79.43), positive predictive
value of 75% (95% CI 66.79 to 82.42), and area under curve
AUC 0.8518 (standard error SE 0.0265) (Table 3).
As CATest was validated in a sample of patients with
cognitive disorder (MCD, MiCD, and normal performance);
a second ROC curve was developed (Figure 1) to select the
cut-off point to classify the participants as MiCD from the
cognitive disorder sample. The most accuracy cut-off for this
goal was 14. The CATest accuracy at this point was 88.5 95%
CI (83.33-92.21) and AUC 0.95 (Table 3).
CATest time application was calculated in the study sam-
ple, an average of 3 minutes and 55 seconds (SD 54 seconds).
4. Discussion
As a result of this study we obtain the validation of a new short
cognitive test for the detection of MiCD in population with 50
years and older. For screening context, CATest has sensitivity
of 84.3% (95% CI 76 to 90.16), specificity of 71.4% (95% CI
61.80 to 79.43), and accuracy of 0.84, which classifies it as a
test of moderate accuracy.
CATest accuracy can be better (accuracy 0.95) if the
purpose is to classify a patient from a population with cogni-
tive disorder (MCD and MiCD); that is, when the objective
of the test is to classify the degree of cognitive disorder.
In relation to the characteristics that are attributed to a
short test [34], characteristics of sensitivity and specificity
above 80% are desired, which according to the confidence
intervals of CATest is met in this study. Another important
characteristic is the accuracy that the previous study suggests
should be greater than 0.8 and it is also true for the validated
test that the value of the desired accuracy is enclosed within
the 95% confidence limits calculated for the general pop-
ulation from the sample. Although the performance of the
test is not the performance of a perfect test, we found that
CATest has better performance for detection of MiCD than
MiniMental (pooled sensitivity less than 70%, accuracy 0.73)
[35–37], which is the most recognized cognitive test [22]
and others reported in the literature(test your memory, ACE/
ACE-R, CAMCOG) [37] and similar performance to MoCA
test [25, 36–38].
A recent meta-analysis [37] aimed at finding and measur-
ing the diagnostic accuracy of short cognitive tests published
in the literature found 9 different cognitive tests, among them
MMSE, MoCA, clock drawing test, and recall test had the
major number of studies and participants; the meta-analysis
qualified as having good methodological quality according to
the AMSTAR 2 tool reports that the recall tests have the best
overall accuracy given by a sensitivity(S) 89% and a specificity
(Sp) of 84%. Despite the performance of this test, it has the
6 International Journal of Alzheimer’s Disease
difficulty of evaluating only the memory domain. Amnesic
cognitive disorders correspond to only 60% of cognitive
disorders, so the use of this unique test would be less sensitive
if the detection of other types of cognitive disorders is sought.
In relation to MoCA, CATest presents a similar perfor-
mance(S: 83% and Sp: 75%) [37]; however, CATest has an
advantage on MoCA as a result of the application time (4
minutes for CATest versus 10 minutes for MoCA [39]), which
would facilitate the use of CATest in primary care settings.
The main strength of this study is the homogeneity of the
diagnostic criteria that were defined a priori, as well as the fact
that the study was assembled in a cohort, with strict selection
criteria for its participants, which reduces the probability of
including biases, ensuring internal validity.
In contrast, the special susceptibility of diagnostic test
studies to the location where they are developed is known by
reports in the literature, since the characteristics of the
study sample are usually different from those of the general
population, compromising external validity. In our study, a
Colombian reference center in attention of cognitive disorder
was the location; however, preventive measures of this selec-
tion bias were controlled with rigorous design, achieving that
the sample will be made up of volunteers from a public call in
the media. One of the main limitations of this study is the high
prevalence of CD in the sample, since it has been reported
that it can behave as a bias that directs the results of accuracy
towards over estimation [40]. Therefore, the results of this
study should be interpreted with caution in scenarios with
lower prevalence, as well as with populations with lower edu-
cational levels than those of our sample, since the measure-
ment of cognitive performance is especially vulnerable to this
type of characteristics.
Another aspect that should be considered in the interpre-
tation of the results of sensitivity and specificity is the value
corresponding to the margin of error that is evident in the
wide of the confidence intervals and that are a consequence
of the size of the sample used for the validation of the CATest.
Future studies are necessary to verify the performance
results of CATest in different scenarios (educational level, eti-
ology of cognitive disorder, CD prevalence, and populations
from other nationalities) to determine its reliability, as well
as studies of direct comparisons with other tests of a similar
nature, in order to obtain more precise results.
In conclusion, CATest is an alternative with adequate
performance for the detection of cognitive disorder after 50
years. The ease of qualification and the short application time
make it an attractive proposal for primary care scenarios.
Additionally, the free use of restrictions makes CATest a use-
ful alternative in daily clinical practice, educational, and re-
search scenarios.
Data Availability
The data used to support the findings of this study are includ-
ed within the article.
Disclosure
The funding source did not influence the study design, anal-
ysis of data, or report of results.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgments
The authors would like to gratefully acknowledge the staff of
National University neurosciences group specially those who
worked in the follow-up of patients as well as the participants
for the commitment, time, and dedication; without their help,
this study would not be possible. This work was supported by
the National University of Colombia (Cod 34663 2016-2018).
Supplementary Materials
Supplementary file 1: cognitive assessment test (CATest)
instrument English version. Supplementary file 2: cogni-
tive assessment test (CATest) instrument Spanish version.
(Supplementary Materials)
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